Group sessions - Neonatal lecture

Question 1

Define neonatal period and infancy

Define gestational age, normal gestation time, preterm time

Answer 1

Neonatal period: first 28 days of life
Infancy: first 1 year of life

Gestational age is the time elapsed between the first
day of the LMP and the day of delivery

Normal gestation: 37+0 to 41+6

Preterm: born before 37+0; post-term: born after
41+6.

Question 2

Define birth weight categories

Define SGA/LGA/Appropriate-for-date

Answer 2

Birth weight categories
≤1000gm = Extremely Low Birth Weight (ELBW)
≤1500gm = Very Low Birth Weight (VLBW)
≤ 2500gm = Low Birth Weight (LBW)

Small-for-date (SGA): BW <10th percentile
Large-for-date (LGA): BW >90th percentile
Appropriate-for-date: BW 10-90th percentile

Question 3

Define normal newborn growth parameters at 37 and 40 weeks (length and weight)

Define normal head circumference at 40 weeks

Answer 3

Question 4

Compare fetal vs post-natal circulation

Answer 4

Babies subjected to hypoxia > pulmonary vessel constricted > prolonged asphyxiation > Persistent pulmonary hypertension of the newborn (PPHN)

PPHN happens when your baby’s pulmonary arteries don’t open up enough, so your baby’s brain and organs don’t get enough oxygen.

Question 5

Consequence of perinatal asphyxiation

Answer 5

Primary apnea: heart rate and BP increase, regular increased breathing/ ventilation
Secondary apnea: HR and BP drops, breathing pattern become erratic

(clinically differentiate the two stages is by tactile stimulation: crying means primary apnea, and no crying means secondary apnea and requires immediate PPV)

Question 6

Causes of neonatal asphyxiation

Answer 6

In-utero hypoxia
¡ Placental abruptio, placenta praevia, twin-twin transfusion syndrome

Intrapartum hypoxia
¡ Uterine hyperstimulation
¡ Shoulder dystocia

Postnatal hypoxia
¡ Poor respiratory drive e.g. preterm infant, drug-induced
depression
¡ Poor cardiopulmonary function e.g. RDS, meconium
aspiration

Question 7

Resuscitation methods for neonatal asphyxia

Answer 7

Helps to establish transition from fetal to post-natal circulation as quickly as possible
¡ Keep warm
¡ Airway opening – suction, position neck
¡ Tactile stimulation
¡ Positive pressure ventilation
¡ External chest compression
¡ Drug administration

Question 8

Cord clamping

• Benefits of delayed clamping
• Drawback
• Timing

Answer 8

Delayed clamping of cord for 30-60 seconds or until
pulsation stops is beneficial
¡ Less iron deficiency anemia
¡ Less intraventricular hemorrhage of preterm infants

Drawback: higher degree of jaundice (1/3 fetal blood still in placental circulation)

Question 9

Outline the Apgar scores and classes

Interpretation

Answer 9

Scored at 1st and 5th minutes of life
¡ ≥7 normal
¡ ≤3 abnormal
¡ Poor AS associated with neonatal mortality
¡ Poor late AS associated with poor neurological outcome

No need to wait for 1st minute score if resuscitation is needed immediately

Question 9

Routine postnatal care

Outline care plan

Answer 9

Early skin-to-skin contact
¡ Facilitate early breastfeeding experience
¡ Keeping warm

Temperature regulation: Normal temperature
- Skin: 36.0 – 36.5C
- Rectal (core): 36.5 – 37.5C
- Plastic wrap for pre-term infants
- Incubator care for first hours when baby is nursed naked under observation

Question 10

Causes of newborn hypothermia

Temperatures that cause lowest metabolic rate in babies

Temperature difference for preterm or low weight babies

Answer 10

Newborn babies are prone to excessive heat loss
¡ “wet” at birth
¡ high surface area to body mass ratio
¡ little insulating fat in preterm/IUGR
¡ little reserves
¡ hypotonic posture in preterm

Thermoneutral zone: temperature range that must be maintained after birth for lowest metabolism rate

Preterm/ low weight: require higher temperature for thermo-neutral zone

Question 11

Consequences of excessive heat loss and hypothermia

Answer 11

Question 12

Fluid requirement in newborn
Fluid level changes after birth

Answer 12

Water makes up 75% of body weight in term infant; 85-90% in preterm infants

Physiologic contraction of ECW after birth – diuresis
- 5-7% body weight loss for term infants
- 10% body weight loss for preterm infants
- More weight loss than above ranges require review of feeding

Daily fluid intake
- Follow “normal” breast milk production
- 30-60ml/kg/day
- Increase to 150-160ml/kg/day at the end of the first week

Question 13

Cord care in newborn

• Outline care plan
• List cord complications

Answer 13

1. Cord clamping
2. Clean with cool boiled water/ antiseptic solution a few times per day
3. Wait for cord is dislodge by 14 days

Complications:
- True knot over cord
- Patent urachus communicating with bladder: allantoid cyst containing urine
- Umbilical granuloma: remnant of umbilical tissue with discharge
- Patent vitelline duct communicating with bowel
- Omphalitis: infection treated with IV Abx

Question 14

Routine newborn screening plan

Answer 14

Biochemical Screening – umbilical cord blood
- G6PD deficiency (incidence 4.4% in male; 0.5% in
female)
- Thyroid function (TSH) (congenital hypothyroidism -incidence1: 2000-3000)

Universal newborn hearing screening +/- BAEP for work-up investigation

Newborn screening for inborn errors of
metabolism – dried blood spots
- Including 26 inherited metabolic diseases
- e.g. SCID, SMA screening

Question 15

Newborn prophylaxis plan

Answer 15

IMI vitamin K at birth
- prophylaxis against vitamin K deficiency bleeding (VKDB) of newborn (previously called hemorrhagic disease of newborn)

Immunizations
- HBV at birth (+HBIG if mother is HBsAg
carrier)
- BCG before hospital discharge continue routine immunization program at
- MCHC /private sector

Ophthalmia prophylaxis in some countries (not routinely performed in HK)
- Gonococcal conjunctivitis/ chlamydia trachomatis causing blindness
- Prophylaxis with silver nitrate /iodine /antibiotics eye
cream

Question 16

Feeding plan for newborn

Answer 16

MILK for the first six months

Complementary food after six months
- semisolids
- milk continues to provide adequate nutrition and calcium

Breast milk is the best
- Nutritionally adequate for the first 6 months for term infants
- Consider supplement – daily vitamin D for exclusively breast-feeding mothers
- feeding up to 2 years and beyond

Question 17

Sleeping suggestions for newborn

Answer 17

Supine preferable (prone position associated with a
higher chance of sudden infant death; lateral position also slightly higher risk)

No pillow required, neck flexion might compress airway

Tight bed sheet and no loose blanket

Avoid co-sleep with parents

Avoid smoking

Question 18

Pacifier use

Benefits and drawbacks

Answer 18

Benefits:
- might soothe a fussy baby
- offers temporary distraction
- might help your baby fall asleep
- might ease discomfort during flights
- might help reduce the risk of sudden infant death
syndrome (SIDS)
- disposable

Drawbacks:
- Early pacifier use might interfere with breast-feeding
- baby might become dependent on the pacifier
- might increase the risk of middle ear infections
- Prolonged use might lead to dental problems

Question 19

Aims of newborn examination

Answer 19

• Assess baby’s ability in adapting to extra-uterine
  life especially the cardiopulmonary status
• Look for major congenital anomalies, esp. those
  requiring urgent treatment
• Identify at risk babies that need postnatal
  monitoring and investigation based on perinatal
  history, stage of maturity, variation in size, presence
  of systemic or neurological abnormalities
• Mother’s competence in child care

Question 20

General examination of newborn

P/E features to note

Answer 20

Size, body proportion,maturity

Colour e.g. plethora, pallor, cyanosis, jaundice,
(skin mottling)

Posture

Cutaneous discoloration

Generalized edema

Gross malformation and dysmorphic features

Question 21

(Reasons for difficult newborn P/E)

Answer 21

1. Small size
2. Uncooperative
3. Hypothermia on cold exposure
4. Neurological state varies with sleep, feeding, etc.
5. On going transitional changes in first few days of life (e.g. changes in pulmonary pressure will affect the signs related to congenital heart disease i.e. VSD murmur cannot be heard clearly for a long time)
6. Impact of intrauterine pressure effect (deformation)
   and birth process e.g. head molding, abnormal posture associated with breech presentation

Question 22

Answer 22

vernix caseosum

Vernix caseosa is a white, creamy, naturally occurring biofilm covering the skin of the fetus during the last trimester of pregnancy. Vernix coating on the neonatal skin protects the newborn skin and facilitates extra-uterine adaptation of skin in the first postnatal week if not washed away after birth.

Question 23

Answer 23

Erythema toxicum is a common rash seen in full-term newborns. It usually appears in the first few days after birth and fades within a week. Up to half of all newborns will have erythema toxicum

Question 24

Answer 24

A Mongolian spot, also known as slate grey nevus or congenital dermal melanocytosis, is a benign, flat, congenital birthmark with wavy borders and an irregular shape.

Question 25

Outline exam of newborn head and face

Answer 25

Head - size (head circumference) and shape - sutures and fontanelles, anterior fontanelle pressure - caput succedenum, cephalhaematoma, subaponeurotic haemorrhage Face - dysmorphic features - mouth lesion e.g. cleft palate - eyes

Question 26

Answer 26

A stork bite, also known as a salmon patch, is a cluster of pink to reddish-purple blood vessels (capillaries) that appear on a newborn's skin on the back of their head or neck. A stork bite is a type of birthmark. Stork bites are harmless and may fade over time. About 50% of adults still have stork bites.

Question 27

Answer 27

Cephalohaematoma: does not cross suture line, usually caused by repeated compression during vaginal birth Subapeneurotic hematoma: bleeding under aponeurosis, crosses suture line/ midline, collection of 200-300mL blood, results in anemia and shock, ears are pulled forward from normal position Scalp edema is a benign ddx

Question 28

Outline exam of newborn neck and skeletal system

Answer 28

Neck - sternomastoid tumour, cystic hygroma - redundant skin fold, web neck - fractured clavicles Limbs - length, soft tissue, nails and digits, deformities - developmental dysplasia of hips (Ortolani and Barlow tests)

Question 29

Answer 29

Lymphedema is a chronic localised swelling caused due to excessive accumulation of lymphatic fluid in the interstitium and resulting from defective lymphatic drainage [1]. Lymphedema can be primary or secondary. Primary lymphedema results from developmental abnormalities leading to pathological lymphatics. Secondary lymphedema is an acquired dysfunction of normally developed lymphatics [1] [2]. Congenital subtype of primary lymphedema is defined as swelling that has an onset at birth up to two years [3]. Primary congenital lymphedema affects the lower limbs in the majority of the cases, and unilateral involvement of one of the upper limbs is a rarity

Question 30

Answer 30

Trisomy 13 (also called Patau syndrome) is a genetic disorder in which a person has 3 copies of genetic material from chromosome 13, instead of the usual 2 copies. Rarely, the extra material may be attached to another chromosome (translocation). Symptoms include: * Cleft lip or palate * Clenched hands (with outer fingers on top of the inner fingers) * Close-set eyes -- eyes may actually fuse together into one * Decreased muscle tone * Extra fingers or toes (polydactyly) * Hernias: umbilical hernia, inguinal hernia * Hole, split, or cleft in the iris (coloboma) * Low-set ears * Intellectual disability, severe * Scalp defects (missing skin) * Seizures * Single palmar crease * Skeletal (limb) abnormalities * Small eyes * Small head (microcephaly) * Small lower jaw (micrognathia) * Undescended testicle (cryptorchidism)

Question 31

Answer 31

common reason for congenital clouding of the cornea is congenital glaucoma Other major causes of corneal clouding include the following: * Birth trauma * Peters anomaly * Dermoid tumors (limbal dermoids) * Sclerocornea * Congenital hereditary endothelial dystrophy (CHED) * Mucopolysaccharidoses * Infectious/inflammatory processes

Question 32

Outline cardiopulmonary exam of newborn

Answer 32

Look and Listen: ¡ peripheral vs central cyanosis ¡ stridor, grunting ¡ respiratory distress (tachypnoea, intercostal insucking) ¡ asymmetry in chest movement Feel: ¡ pulses ¡ cardiac impulses Auscultate: ¡ Heart sounds, murmur ¡ Breath sounds, added sounds

Question 33

Define normal cardio-respiratory parameters in newborn

Answer 33

Normal cardio-respiratory parameters ¡ HR 120 (range -90 to160/min), slower when sleeping ¡ Pulses volume equal ¡ Normal apex beat at 5th ICS mid clavicular line ¡ Transient Innocent murmur common ¡ Respiratory rate 40-50 /min, higher in preterm infants with occasional periodic breathing

Question 34

Outline abdominal exam for newborn

Answer 34

Look ¡ shape and size, umbilicus; visible veins, visible peristalsis ¡ External genitalia, perineum ¡ Hernia ¡ Anal patency Feel ¡ Superficial palpation for or obvious mass / tenderness ¡ for liver ( normal 1-2 cm below costal margin soft), spleen, kidneys and other masses Listen ¡ bowel sounds ¡ bruits

Question 35

Answer 35

Hirschsprung's disease (also called congenital aganglionic megacolon) occurs when some of your baby's intestinal nerve cells (ganglion cells) don't develop properly, delaying the progression of stool through the intestines.

Question 36

Answer 36

Imperforate anus or anal atresia is a congenital anorectal malformation (ARM) where a normal anal opening is absent at birth. ARMs comprise of a broad spectrum of defects ranging from minor (e.g., membranous covering) to complex cloacal malformations involving the urinary and genital tracts as well. Picture: Anal atresia with fistula formation

Question 37

Answer 37

Hypospadias is a birth defect in boys in which the opening of the urethra is not located at the tip of the penis. In boys with hypospadias, the urethra forms abnormally during weeks 8–14 of pregnancy.

Question 38

Outline exam of spine and hip in newborn

Answer 38

Back and spine - Spina bifida, swellings, tethered cord - Stigmata of underlying spinal defect –midline dimples, mass, tufts of hair, haemangioma - Deformities e.g. scoliosis Hips - Developmental dysplasia of the hip (DDH)/ congenital dislocation of the hip/ hip dysplasia: hip joint attaches the thigh bone (femur) to the pelvis - Screen with Ortolani and Barlow tests: dislocate and relocate hip

Question 39

Outline neurological exam for newborn

Answer 39

State of alertness Posture e.g. flaccid, spasticity, focal abnormality e.g. Erbs palsy Muscle tone, tendon jerks Spontaneous movements Primitive reflexes –Moro, grasp, suckling, rooting Cranial nerves: eye movements, facial asymmetry, swallowing

Question 40

Normal vs abnormal neurological features in newborn

Answer 40

Norms - Predominantly flexor tone (reduced tone in premature infants) - Sleeping for 18-20 hours/day, most alert mid-way between feeding, irritable when hungry - Best visual at 18 inches but no consistent visual fixation - Concomitant squint Warning signs - Frog like posture - Jitteriness - Altered conscious state - Bulging fontanelles

Question 41

Answer 41

Erb's palsy The infant's arm hangs limply from the shoulder with flexion of the wrist and fingers due to weakness of muscles innervated by cervical roots C5 and C6. Risk factors are macrosomia (large baby) and shoulder dystocia. However, Erb's palsy may occur following cesarian section. An easy way to test for this is to check for the Moro reflex (or startle reflex), a natural response present immediately after birth, which disappears by three to four months of age.